Healthcare Provider Details

I. General information

NPI: 1679561070
Provider Name (Legal Business Name): JOSEPH ROGER PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 WATER AVE
HILLSBORO WI
54634-9054
US

IV. Provider business mailing address

400 WATER AVE
HILLSBORO WI
54634-9054
US

V. Phone/Fax

Practice location:
  • Phone: 608-489-8000
  • Fax:
Mailing address:
  • Phone: 608-489-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberL5092
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number55789
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: